Clean Cut (adaptive, multimodal surgical infection prevention programme) for low-resource settings: a prospective quality improvement study.

BACKGROUND: Clean Cut is an adaptive, multimodal programme to identify improvement opportunities and safety changes in surgery by enhancing outcomes surveillance, closing gaps in surgical infection prevention standards, and strengthening underlying processes of care. Surgical-site infections (SSIs) are common in low-income countries, so this study assessed a simple intervention to improve perioperative infection prevention practices in one. METHODS: Clean Cut was implemented in five hospitals in Ethiopia from August 2016 to October 2018. Compliance data were collected from the operating room focused on six key perioperative infection prevention standards. Process-mapping exercises were employed to understand barriers to compliance and identify locally driven improvement opportunities. Thirty-day outcomes were recorded on patients for whom intraoperative compliance information had been collected. RESULTS: Compliance data were collected from 2213 operations (374 at baseline and 1839 following process improvements) in 2202 patients. Follow-up was completed in 2159 patients (98·0 per cent). At baseline, perioperative teams complied with a mean of only 2·9 of the six critical perioperative infection prevention standards; following process improvement changes, compliance rose to a mean of 4·5 (P < 0·001). The relative risk of surgical infections after Clean Cut implementation was 0·65 (95 per cent c.i. 0·43 to 0·99; P = 0·043). Improved compliance with standards reduced the risk of postoperative infection by 46 per cent (relative risk 0·54, 95 per cent c.i. 0·30 to 0·97, for adherence score 3-6 versus 0-2; P = 0·038). CONCLUSION: The Clean Cut programme improved infection prevention standards to reduce SSI without infrastructure expenses or resource investments.

Severe anaphylactic shock due to repeated application of aprotinin in patients following intrathoracic aortic replacement.

Aprotinin is known to significantly reduce the incidence of perioperative bleeding complications in cardiac, thoracic and vascular surgery. Despite the wide use of this medication in other surgical fields, there are only a few reports of serious adverse side effects. In this paper we report on two patients with severe anaphylactic shock due to repeated administration of aprotinin, who both required cardiopulmonary resuscitation.

[Propofol for induction and maintenance of anesthesia during heart surgery. Results of pharmacological studies in man]. / Propofol zur Einleitung und Aufrechterhaltung der Hypnose bei koronarchirurgischen Eingriffen. Ergebnisse humanpharmakologischer Untersuchungen.

Numerous reports have concluded that propofol is suitable for maintenance of anesthesia by continuous infusion. The aim of this study was to evaluate the use of propofol and fentanyl for coronary bypass surgery in patients with good left ventricular function. The effects of this anesthetic combination on quality of anesthesia, hemodynamic status, and endocrine and metabolic responses were assessed. Postoperative recovery and side effects were also noted. The effects were compared with those of a standard method using etomidate, midazolam, and fentanyl. METHODS. Twenty patients who presented for aortocoronary bypass surgery (NYHA class II-III) were randomly allocated to one of two groups: propofol-fentanyl (group A) or etomidate-midazolam-fentanyl (group B). In each patient the dosage of the drugs was adjusted to obtain the optimum responses during induction and maintenance. RESULTS. Propofol in combination with fentanyl diminished mean arterial pressure (-28.7%) and heart rate (-17.3%) when used for induction in patients with ischemic heart disease, even in low doses and with slow administration. In 5 of the 10 patients it was impossible to prevent a critical fall in coronary perfusion without active intervention. However, during maintenance anesthesia, stable circulatory parameters were obtained with both drug regimens. Clinical signs thought to reflect myocardial ischemia were not observed. In both groups reductions in basal and stimulated catecholamine secretion were demonstrated. Similarly, perioperative cortisol secretion was reduced with both techniques. Despite all the complicated metabolic inhibitory effects seen, preoperative hormonal levels were restored within 1 h of the end of anesthesia. The magnitude and duration of the metabolic changes were found to be related to the duration of surgery. There was no evidence of non-homogeneous tissue perfusion as assessed by increases in lactate concentration, cardiac ischemia, or liver dysfunction in any of the patients. There were no postoperative complications in either group, but the return of consciousness, adequate spontaneous ventilation, and psychomotor activity was more rapid in the propofol patients. CONCLUSION. In summary, it can be concluded that a propofol infusion technique positively enhances the recovery period after cardiac surgery and provides good control during anesthesia. However, the use of propofolfentanyl for induction of anesthesia in patients with limited coronary perfusion is not recommended because of its hypotensive effect.

Total arterial revascularization of the heart using both mammary arteries and the right gastroepiploic artery.

From April 1988 to April 1989, nine patients (seven men and two women) with coronary three-vessel disease and disabling angina underwent elective myocardial revascularization. None of the patients had available veins because of previous bypass procedures (three) or extensive varicosis (six). On standard cardiopulmonary bypass and cardioplegic arrest the right and the left mammary arteries (RIMA, LIMA) and the right gastroepiploic artery (RGEA) were anastomosed each to a major coronary branch (none of them as free graft) in each patient. All patients survived the operation but one, who died 2 weeks after the operation of a bilateral pneumonia. Autopsy revealed patent anastomoses. One patient had to be reexplored for bleeding. Two patients required temporary inotropic support. There was no perioperative myocardial infarction. All survivors were discharged home in an average of 18.7 days after the operation, are free from angina, and all have negative stress tests (mean follow-up 7.7 months) but one with severe coronary atherosclerosis who experiences slight exertional angina despite good patency of the grafts. Five patients were recatheterized after a mean interval of 5.4 months after operation revealing in all cases patent anastomoses. Total revascularization of the heart with arterial grafts is feasible, safe, and it could become the method of choice if patency persists in the long run.

[Anesthesiology experiences in 199 heart transplants]. / Anästhesiologische Erfahrungen bei 199 Herztransplantationen.

From June 1983 to October 1987 199 orthotopic heart transplantations were performed at the Medical School of Hannover. Eighty percent of the organs were explanted in foreign hospitals. Since the cold ischemic time lasts less than 4 hours, a sophisticated transport system is essential. The selection of donors (dissociated brain death, age less than 35 years, systolic blood pressure greater than 70 mm Hg, intensive care for less than 7 days) and recipients (age between 10 and 55 years, final stage of irreversible myocardial insufficiency) is governed by strict criteria. A fixed pulmonary hypertension of more than 8 Wood is an absolute contraindication. The pulmonary wedge pressure and the right atrial pressure are preoperatively raised more than three times from normal. The ejection fraction is reduced to 10%. Seventy percent of the patients suffer from dilated cardiomyopathy. The premedication with flunitrazepam is given orally. Anaesthesia is induced with fentanyl and etomidate followed by pancuronium for intubation. During the time of induction all lines have to be inserted under sterile conditions. For weaning from the heart lung machine always catecholamines (isoproterenol, adrenaline) are applied in combination with vasodilators (nitroglycerin, DHB). Postoperatively patients will be extubated after 17.8 +/- 2.2 hours. Rejection episodes belong to the most threatening sort of complications. For this reason endomyocardial biopsies are done routinely.

Treatment of extensive aortic aneurysms by a new multiple-stage approach.

A new multiple-stage approach to extensive aneurysmal disease of the aorta is presented. The method is designed to obviate the proximal graft-to-aorta anastomosis in second-stage and third-stage aortic replacement to simplify and facilitate these operative steps. Since 1981 a total of 17 such procedures were performed in seven patients with dissecting and nondissecting aneurysms without deaths or complications related to the method.

[Left atrial catheter following puncture of the jugular vein]. / Linksatrialer Katheter nach Punktion der Vena jugularis.

This is a report on the insertion of a central venous catheter into the right jugular vein which was abnormally directed through the lung tissue into the left atrium.

[Heart transplantation in cardiomyopathy]. / Herztransplantation bei Kardiomyopathie.

Within the spectrum of presently accepted candidates for heart transplantation, end-stage heart failure in dilated cardiomyopathy has become the principle indication. Although several indicators of poor prognosis have been specified, the decision for heart transplantation is primarily made on clinical grounds. Expected long-term survival after transplantation is 60 to 80% at one year and more than 50% at five years. Since July, 1983, 50 patients underwent orthotopic heart transplantation, 38 of whom had been suffering from dilated cardiomyopathy. Ages ranged from nine to 54 years with a mean of 40 years. At present, 38 patients are alive, 34 are discharged from hospital, 14 have returned to work or school. Physical capacity and cardiac function are normal. There was no difference between the cardiomyopathy patients and the coronary artery disease patients with respect to rate and severity of rejection episodes, infection and long-term findings. Heart transplantation is considered a promising routine treatment for end-stage heart failure in particular in younger patients with dilated cardiomyopathy.

[Cardiocirculatory effects of a new sympathomimetic, amezinium methyl sulfate. Results of human pharmacological studies]. / Kardiozirkulatorische Effekte des neuen Sympathomimetikums Ameziniummetilsulfat. Ergebnisse humanpharmakologischer Studien.

Changes in haemodynamic, inotropic state, and myocardial oxygen consumption were investigated in a total of eight patients with coronary artery disease after intravenous injection of 0.07 mg/kg amezinium methyl sulfate (LU 1631, Supratonin). It was demonstrated, that the principal effects of amezinium are consistent with those of a sympathomimetic agent which stimulates vascular alpha- and beta 1-adrenoreceptors. Amezinium (0.07 mg/kg) increased cardiac index, mean arterial pressure and total systemic resistance and dp/dtmax, while there were only minor changes in stroke index, mean pulmonary pressure and total pulmonary vascular resistance. In accordance with the changes in haemodynamics there was a 21.5% increase in myocardial oxygen consumption. But there were no signs of imbalance between oxygen supply and oxygen demand.

[Evaluation of palmar collateral circulation with the Oxygenmet oxygen saturation measurement device]. / Prüfung des Hohlhand-Kollateralkreislaufs mit dem Sauerstoffsättigungsmessgerät Oxygenmet.

Assessment of collateral circulation of the palmar arcade prior to percutaneous radial artery cannulation is necessary because a thrombosing radial artery together with insufficient collateral circulation may lead to gangrene of the hand. A new method for assessment of collateral circulation of the palmar arcade by use of a spectrophotometric monitoring device for arterial oxygen saturation is described. This method is contrasted with current methods (Allen's test, Brodsky's test, ultrasound Doppler).

[Beroset Y 23 G--a new teflon indwelling catheter]. / Beroset Y 23 G--eine neue Teflon-Verweilkanüle.

A new type of FEP-Teflon intravenous cannula has been developed with particular attention being paid to its use in paediatrics. Its advantages are: improved control of the needle tip during venipuncture via improved grip:--additional facility for injection or blood sampling via side arm--comfortable easy strapping via flat hub.

[Therapeutic use of amezinium methylsulfate--a new, long acting, sympathomimetic--in paraspinal conduction anesthesia]. / Therapeutische Anwendung von Ameziniummetilsulfat--einem neuen, langwirkenden Sympathikomimetikum--bei rückenmarksnaher Leitungsanästhesie.

Cardiovascular effects of the new sympathomimetic ameziniummetilsulphate were investigated in 25 patients compared with a control group (n = 25). During spinal/epidural anaesthesia 5 mg amezinium was given i.v. if blood pressure dropped greater than 20 mmHg. from starting-point. A significant recovery of blood pressure (epidural anaesthesia: syst 21%, diast 9%; spinal anaesthesia: syst 13%, diast 6.6%) and a decrease in heart rate (6.8% resp. 4,5%) were thought due to peripheral vasoconstriction. Amezinium proved a stimulating drug for alpha- and beta 1-receptors by stabilising the systemic blood pressure in spinal/epidural anaesthesia.

[Roentgen contrast medium representation, a possibility for controlling catheter placement in continuous brachial plexus anesthesia]. / Röntgenkontrastmitteldarstellung, eine Kontrollmöglichkeit zur Identifizierung der Katheterlage bei kontinuierlicher Plexus-Anaesthesie des Arms.

The correct positioning of catheters for continuous plexus brachialis anaesthesia/analgesia in uncooperative patients via x-rays is reported.

[Modification of cardiac circulation and respiratory parameters by alfentanil]. / Beeinflussung der Herz-Kreislauf- und Ventilationsparameter durch Alfentanil.

In 93 patients (ASA I) undergoing orthopaedic operations respiratory and haemodynamic effects of alfentanil (steady state: spontaneous breathing halothane, N2O/O2) were measured. After injection of alfentanil apnoea was found be readily antagonized by Naloxone. A significant decrease of arterial pressure and heart rate occurred simultaneously independent of dose level. The decrease of arterial pressure could be prevented by pre-injection of atropine. Therefore an increased vagal tone must be responsible for depression of haemodynamic parameters.

[Changes in ventricle dynamic data in geriatric patients during spinal anesthesia. Results of a polymechanocardiographic study]. / Veränderungen ventrikeldynamischer Daten bei geriatrischen Patienten nach Spinalanaesthesie. Ergebnisse einer polymechanocardiographischen Studie.

Systolic time intervals were performed in 14 elderly patients after spinal anaesthesia. The following parameters were measured or calculated: Heart rate (HR), total electromechanical systole (QS2), pre ejection period (PEP), isometric contraction time (ICT), left ventricular ejection time (LVET), 1/PEP2, PEP/LVET and pdiast/RS1. There was a significant increase of the relation of the pre ejection period to left ventricular ejection time (PEP/LVET), while there were lower values for 1/PEP2 and pdiast/RS1 ratio. The data suggest that compensatory cardiac activity following spinal anaesthesia in geriatric patients is remarkable diminished in contrast to young people.